Patient Satisfaction: Who’s Paying the Price for Happy Patients?

“Happy cows come from California,” or so the saying goes. But where do happy patients come from? Wisconsin.

At least that’s what a 2013 post said on NPR’s Shots blog, that looked at Medicare reimbursement rates that were in part based on patient satisfaction scores. Hospitals with higher satisfaction rates included those in Maine, Massachusetts, Nebraska, New Hampshire, North Carolina, Utah and Wisconsin. Those getting reduced reimbursement included hospitals in California, Connecticut, Nevada, New Mexico, New York, North Dakota, Washington and Wyoming.

I admit I was skeptical when I first heard about the patient satisfaction component to Medicare reimbursement that was part of the Affordable Care Act. I still am a bit. I definitely think patients should be satisfied with their experiences and get the best care they can get, but I’ve often felt like institutional attempts to make patients happy are attempts to cover up for poor patient care.

I’ve been to physicians’ offices that could rival hotel lobbies only to have those practitioners miss important and life-threatening diseases. Sure it looked nice and they had free coffee, but when it came down to giving good medical care their meticulously designed waiting room was of no help.

It seems I’m not alone in my skepticism. Recently I’ve run across some voices who claim patient satisfaction is doing more than acting as a distraction to subpar care; it’s actually driving poor quality and non-evidence-based practice.

Steven Salzberg a columnist for Forbes is not one who thinks the patient is always right. In his opinion piece, “Dr. House Was Right: Give Patients What They Need, Not What They Want” Salzberg proclaims his love of the TV show “House,” as well as a preference for competence over bedside manner. In other words, he’d gladly receive care from the prickly Dr. House, who is known for always being right and not necessarily giving patients what they want, than to have a nice or kind doctor who accommodates his requests.

Salzberg thinks the physician should run the show and the patient should be a grateful and quiet participant in his or her care. Of course he’s talking about actual medical procedures, not preventative care and general health maintenance.

Salzberg mentions another voice against patient satisfaction ratings influencing patient care, William Sonnenberg, MD. Sonneberg wrote a piece for Medscape in March 2014 called Patient Satisfaction is Overrated. In the piece he brings up a point regarding satisfaction scores that I had not before considered—dependence on patient satisfaction scores, specifically Press Ganey, can lead to poorer patient care.

How? He shares the story of a colleague who approached him after Sonnenberg gave a presentation about RSV treatment. Sonnenberg advocated for educating parents (RSV most commonly affects children) on the course of the virus, which he said would keep the child out of the ER or urgent care center thus preventing them from being prescribed unneeded antibiotics.

To me this actually sounds reasonable and like great patient-centered care—educating the family and preventing unnecessary treatment. What patient wouldn’t be happy with that?

The colleague, however, told Sonnenberg that while he agreed, this treatment plan wouldn’t fly thanks to patient satisfaction scores. Basically, the colleague felt obligated to prescribe antibiotics because it would make the parents “happy.” As I see it, he was saying his prescribing antibiotics would make the parents feel like the he was listening to their concerns and taking action, thus improving the satisfaction scores he would receive from them. The fear of getting a talking to from hospital administration and losing reimbursement dollars was affecting the way this physician treated his patients.

Siebert says that conservative treatment like over-the-counter NSAIDS and physical therapy will likely lead to unhappy patients and poor satisfaction scores. However, she points out, over prescribing controlled medications is not necessarily practicing responsible medicine. Physicians are left with two choices. 1.) Risk getting poor satisfaction scores that lower Medicare reimbursement and make hospital administrators very unhappy. Or, 2.) Unnecessarily prescribe controlled substances to create happy, but drug-dependent patients and receive good satisfaction scores.

Neither option seems appealing to me.

So what exactly is being asked on the patient satisfaction surveys that put physicians, and healthcare professionals in general between such a rock and a hard place? You can find a copy of Medicare’s survey here. On it you’ll find questions like:

During this hospital stay, how often did the nurses treat you with courtesy and respect?

During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?

During this hospital stay, how often did your doctors listen to you carefully?

During this hospital stay, how often did the staff do everything they could to help you with your pain?

Would you recommend this hospital to your friends and family?

When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.

The questionnaire is about 12 pages long but this is a good sampling of some of the questions asked on it. What strikes me about the questions is that they are vague. How is courtesy and respect defined? Is it comfy couches and free beverages in the waiting area? What’s a reasonable time to wait for a call light to be answered because, let’s face it, unless you have one-to-one staffing it’s impossible for nurses answer call lights within 30 seconds. How specifically is a doctor’s “listening carefully” defined?

Because of the vagueness of the questions, I can see why physicians feel frustrated. Without specific markers you can’t get a good feeling for what exactly patients are dissatisfied about. Perhaps a better question is, “Was your call button answered within 15 minutes or less?”

Instead of making healthcare into a situation where the patient is always right and the healthcare staff is always wrong, or like in Dr. House’s case, a situation where the doctor is always right and the patient is always wrong, we need to focus on working with the patient as part of a team. Healthcare providers need to listen to the patient, explain the rational behind treatment plans and work with the patient to ensure the best outcomes. Those outcomes need to be taken into account when analyzing these scores.

Patients, in turn, need to admit that they play a key role in satisfaction. They must be willing to ask questions about a treatment plan, voice their concerns if they think it won’t work and be open to honestly trying the provider’s recommended course of care. In truth, we all know or have been patients who want easy fixes to things like obesity or pain control and aren’t willing to try more conservative measures like diet and exercise or physical therapy before jumping to surgery or prescriptions.

Let’s be honest, patient satisfaction is a two way street.

A survey with raw scores isn’t enough to tell us what is really going on when it comes to patient satisfaction. Is patient satisfaction important? Yes, but we must find a way to measure it so it captures the whole situation rather than data point on the radar.

What do you think would be the best way to measure patient satisfaction? Is there a better way than Press Ganey? We’d love to hear your ideas below in the comments, or you can tweet them to me @Jen_NurseEditor.

Jennifer Thew, RN, MSJ

Jennifer Thew, RN, MSJ, is a registered nurse and journalist who has covered healthcare issues and how they relate to the nursing profession. She began her nursing career as a neuroscience nurse at Rush University Medical Center in Chicago and then transitioned to journalism after receiving a degree from Roosevelt University in Chicago. She has edited and written numerous articles on a wide range of nursing and healthcare topics like Accountable Care Organizations, evidence-based practice and telehealth.

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